Transplante hepático sequencial com preservação da veia cava inferior (técnica de "Duplo Piggyback") : uma técnica original

RESUMO:Desde a declaração de Bethesda em 1983, a transplantação hepática é considerada um processo válido e aceite na prática clínica para muitos doentes com doença hepática terminal, relativamente aos quais não houvesse outra alternativa terapêutica. Em 1991, por proposta de Holmgren, professor de genética, o cirurgião sueco Bo Ericzon realizou em Huntingdon (Estocolmo) o primeiro transplante hepático num doente PAF (Polineuropatia Amilloidótica Familiar), esperando que a substituição do fígado pudesse frenar a evolução da doença. Nesta doença hereditária autossómica dominante, o fígado, apesar de estrutural e funcionalmente normal, produz uma proteína anormal (TTR Met30) responsável pela doença. A partir de então, a transplantação hepática passou a ser a única terapêutica eficaz para estes doentes. Portugal é o país do mundo com mais doentes PAF, tendo sido o médico neurologista português Corino de Andrade quem, em 1951, identificou e descreveu este tipo particular de polineuropatia hereditária, também conhecida por doença de Andrade. Com o início da transplantação hepática programada em Setembro de 1992, o primeiro doente transplantado hepático em Portugal, no Hospital Curry Cabral, foi um doente PAF. Desde logo se percebeu que a competição nas listas de espera em Portugal, entre doentes hepáticos crónicos e doentes PAF viria a ser um problema clínico e ético difícil de compatibilizar. Em 1995, Linhares Furtado, em Coimbra, realizou o primeiro transplante dum fígado dum doente PAF num doente com doença hepática metastática, ficando este tipo de transplante conhecido como transplante sequencial ou “em dominó”. Fê-lo no pressuposto de que o fígado PAF, funcional e estruturalmente normal, apesar de produzir a proteína mutada causadora da doença neurológica, pudesse garantir ao receptor um período razoável de vida livre de sintomas, tal como acontece na história natural desta doença congénita, cujas manifestações clínicas apenas se observam na idade adulta. A técnica cirúrgica mais adequada para transplantar o doente PAF é a técnica de “piggyback”, na qual a hepatectomia é feita mantendo a veia cava do doente, podendo o transplante ser feito sem recorrer a bypass extracorporal. Antes de 2001, para fazerem o transplante sequencial, os diferentes centros alteraram a técnica de hepatectomia no doente PAF, ressecando a cava com o fígado conforme a técnica clássica, recorrendo ao bypass extracorporal. No nosso centro imaginámos e concebemos uma técnica original, com recurso a enxertos venosos, que permitisse ao doente PAF submeter-se à mesma técnica de hepatectomia no transplante, quer ele viesse a ser ou não dador. Essa técnica, por nós utilizada pela primeira vez a nível mundial em 2001, ficou conhecida por Transplante Sequencial em Duplo Piggyback. Este trabalho teve como objectivo procurar saber se a técnica por nós imaginada, concebida e utilizada era reprodutível, se não prejudicava o doente PAF dador e se oferecia ao receptor hepático as mesmas garantias do fígado de cadáver. A nossa série de transplantes realizados em doentes PAF é a maior a nível mundial, assim como o é o número de transplantes sequenciais de fígado. Recorrendo à nossa base de dados desde Setembro de 1992 até Novembro de 2008 procedeu-se à verificação das hipóteses anteriormente enunciadas. Com base na experiência por nós introduzida, a técnica foi reproduzida com êxito em vários centros internacionais de referência, que por si provaram a sua reprodutibilidade. Este sucesso encontra-se publicado por diversos grupos de transplantação hepática a nível mundial. Observámos na nossa série que a sobrevivência dos doentes PAF que foram dadores é ligeiramente superior àqueles que o não foram, embora sem atingir significância estatística. Contudo, quando se analisaram, apenas, estes doentes após a introdução do transplante sequencial no nosso centro, observa-se que existe uma melhor sobrevida nos doentes PAF dadores (sobrevida aos 5 anos de 87% versus 71%, p=0,047).Relativamente aos receptores observámos que existe um benefício a curto prazo em termos de morbi-mortalidade (menor hemorragia peri-operatória) e a longo prazo alguns grupos de doentes apresentaram diferenças de sobrevida, embora sem atingir significância estatística, facto este que pode estar relacionado com a dimensão das amostras parcelares analisadas. Estes grupos são os doentes com cirrose a vírus da hepatite C e os doentes com doença hepática maligna primitiva dentro dos critérios de Milão. Fora do âmbito deste trabalho ficou um aspecto relevante que é a recidiva da doença PAF nos receptores de fígado sequencial e o seu impacto no longo prazo. Em conclusão, o presente trabalho permite afirmar que a técnica por nós introduzida pela primeira vez a nível mundial é exequível e reprodutível e é segura para os doentes dadores de fígado PAF, que não vêem a sua técnica cirúrgica alterada pelo facto de o serem. Os receptores não são, por sua vez, prejudicados por receberem um fígado PAF, havendo mesmo benefícios no pós-operatório imediato e, eventualmente, alguns grupos específicos de doentes podem mesmo ser beneficiados.---------ABSTRACT: Ever since Bethesda statement in 1983, Liver Transplantation has been accepted as a clinical therapeutic procedure for many patients with advanced hepatic failure Holmgren, professor of genetics, suggested that one could expect that transplanting a new liver could lead to improve progressive neurological symptoms of Familial Amyloidotic Polyneuropathy (PAF). Bo Ericzon, the transplant surgeon at Huddinge Hospital in Stockholm, Sweden, did in 1991 the first Liver Transplant on a FAP patient. FAP is an inherited autosomal dominant neurologic disease in which the liver, otherwise structural an functionally normal, produces more than 90% of an abnormal protein (TTR Met30) whose deposits are responsible for symptoms. Liver Transplantation is currently the only efficient therapy available for FAP patients. Portugal is the country in the world where FAP is most prevalent. The Portuguese neurologist Corino de Andrade was the first to recognize in 1951 this particular form of inherited polyneuropathy, which is also known by the name of Andrade disease. Liver Transplantation started as a program in Portugal in September 1992. The first patient transplanted in Lisbon, Hospital Curry Cabral, was a FAP patient. From the beginning we did realize that competition among waiting lists of FAP and Hepatic patients would come to be a complex problem we had to deal with, on clinical and ethical grounds. There was one possible way-out. FAP livers could be of some utility themselves as liver grafts. Anatomically and functionally normal, except for the inherited abnormal trace, those livers could possibly be transplanted in selected hepatic patients. Nevertheless the FAP liver carried with it the ability to produce the mutant TTR protein. One could expect, considering the natural history of the disease that several decades would lapse before the recipient could suffer symptomatic neurologic disease, if at all. In Coimbra, Portugal, Linhares Furtado performed in 1995 the first transplant of a FAP liver to a patient with metastatic malignant disease, as a sequential or “domino” transplant. FAP Liver Transplant patients, because of some dysautonomic labiality and unexpected reactions when they are subjected to surgery, take special advantage when piggyback technique is used for hepatectomy. This technique leaves the vena cava of the patient undisturbed, so that return of blood to the heart is affected minimally, so that veno-venous extracorporeal bypass will not be necessary. The advantages of piggyback technique could not be afforded to FAP patients who became donors for sequential liver transplantation, before we did introduce our liver reconstruction technique in 2001. The hepatectomy took the vena cava together with the liver, which is the classical technique, and the use of extracorporeal veno-venous bypass was of necessity in most cases. The reconstruction technique we developed in our center and used for the first time in the world in 2001 consists in applying venous grafts to the supra-hepatic ostia of piggyback resected FAP livers so that the organ could be grafted to a hepatic patient whose liver was itself resected with preservation of the vena cava. This is the double piggyback sequential transplant of the liver. It is the objective of this thesis to evaluate the results of this technique that we did introduce, first of all that it is reliable and reproducible, secondly that the FAP donor is not subjected to any additional harm during the procedure, and finally that the recipient has the same prospects of a successful transplant as if the liver was collected from a cadaver donor. Our series of liver transplantation on FAP patients and sequential liver transplants represent both the largest experience in the world. To achieve the analysis of the questions mentioned above, we did refer to our data-base from September 1992 to November 2008. The reconstructive technique that we did introduce is feasible: it could be done with success in every case ion our series. It is also reproducible. It has been adopted by many international centers of reference that did mention it in their own publications. We do refer to our data-base in what concerns the safety for the FAP donor.Five years survival of FAP transplanted patients that have been donors (n=190) has been slightly superior to those who were not (n=77), with no statistical significance. However, if we consider five year survival of FAP transplanted patients after the beginning of sequential transplant program in our center, survival is better among those patients whose liver was used as a transplant (87% survival versus 71%, p=0.047). In what concerns recipients of FAP livers: Some short-term benefit of less perioperative morbi-mortality mainly less hemorrhage. In some groups of particular pathologies, there is a strong suggestion of better survival, however the scarcity of numbers make the differences not statistically significant. Patients with cirrhosis HVC (83% versus73%) and patients with primitive hepatic cancer within Milan criteria (survival of 70% versus 58%) are good examples. There is one relevant problem we left beyond discussion in the present work: this is the long-term impact of possible recurrence of FAP symptoms among recipients of sequential transplants. In Conclusion: The reconstruction technique that we did develop and introduce is consistently workable and reproducible. It is safe for FAP donors with the advantage that removal of vena cava can be avoided. Hepatic patients transplanted with those livers suffer no disadvantages and have the benefit of less hemorrhage. There is also a suggestion that survival could be better in cirrhosis HVC and primary liver cancer patients.

Program Catapultas: Education for development in Bairro Padre Cruz

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Economics from the NOVA – School of Business and Economics

Contract-program evaluation: Impact of the DRG classification system on hospitals' outputs

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Management from the NOVA – School of Business and Economics

The effectiveness of a teacher’s training workshop on Media Smart Program

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Management from the NOVA – School of Business and Economics

The effectiveness of the Media Smart Program on promoting the critical thinking of children towards the use of celebrities in television advertising

A Work Project, presented as part of the requirements for the Award of a Masters Degree in Management from the NOVA – School of Business and Economics

Social impact bond feasibility study: Children and youth at risk: the Projecto Família program

Social impact bonds are an increasingly popular method of unlocking typical social investment barriers and fuelling social innovation. This feasibility study aims to understand whether a social impact bond is a suitable tool for decreasing unnecessary foster care placements in Portugal, which have been proven to cause significant social and financial damage to societies. This research question is answered through a financial model which combines the costs of this social problem with Projecto Família’s intervention model, a leading intensive family preservation service. Main findings suggest using SIB funding for a 5-year project with the goal of generating the proper impact measurement metrics lacking in the field.

A description of the Australian early psychosis intervention model and a proposal to establish a Pilot Early Intervention Program in Santa Cruz de la Sierra, Bolívia

RESUMO: Em 2011, a Associação Psiquiátrica Mundial lançou um programa de bolsas de investigação para psiquiatras em início de carreira a partir de países de renda baixa ou média-baixa, no âmbito deste programa, o autor foi selecionado para uma bolsa de pesquisa no Centre for Youth Mental Health/Orygen Youth Health Research Centre da Universidade de Melbourne. Orygen, é a principal organização de pesquisa e tradução do conhecimento do mundo com foco em problemas de saúde mental em pessoas jovens. O estágio foi baseado em Prevenção e Intervenção Precoce Psychosis Centre (EPPIC), que faz parte do Orygen. EPPIC fornece programa de tratamento abrangente e integrada, baseada na comunidade para o primeiro episódio de psicose. Esta dissertação descreve o modelo EPPIC, e seus componentes essenciais e fatores que são necessários para uma implementação de serviço direito. Além disso, uma proposta de criação de um programa-piloto de intervenção psicose precoce é discutido. Este programa inclui um programa de extensão inovadora que combina princípios comerciais sólidos, com metas sociais, a fim de combater especificamente a maior barreira para o tratamento da psicose precoce na Bolívia: o estigma da doença mental. Ao utilizar uma equipe de tratamento móvel, multidisciplinar, que enfatiza os papéis dos gerentes do caso treinados focada em fornecer indivíduo intensiva e apoio familiar no lar, este programa irá prestar cuidados culturalmente apropriados que irá alavancar contribuições de um suprimento limitado de psiquiatras e mudar longe da dependência um sistema médico fragmentado. ---------------------------- ABSTRACT: In 2011, the World Psychiatric Association launched a programme of research fellowships for early-career psychiatrists from low- or lower-middle income countries, within this programme, the author was selected to a research fellowship at the Centre for Youth Mental Health/Orygen Youth Health Research Centre at University of Melbourne. Orygen, is the world’s leading research and knowledge translation organization focusing on mental ill-health in young people. The traineeship was based on Early Psychosis Prevention and Intervention Centre (EPPIC), which is part of Orygen. EPPIC provides comprehensive, integrated, community-based treatment program for first-episode psychosis. This dissertation describes the EPPIC model, and its core components and factors which are necessary to a right service implementation. Additionally, a proposal to establish a pilot early psychosis intervention programme is discussed. This programme includes an innovative outreach programme that combines sound business principals with social goals in order to specifically target the largest barrier to early psychosis treatment in Bolivia: the stigma of mental illness. By utilizing a mobile, multidisciplinary treatment team that emphasizes the roles of trained case managers focused on providing intensive individual and family support in the home, this programme will provide culturally appropriate care that will leverage contributions from a limited supply of psychiatrists and shift dependence away from a fragmented medical system.

Essays in health economics: Volume-Outcome Effect, upcoding behaviour and the evaluation of a short-term intervention program

Evidence in the literature suggests a negative relationship between volume of medical procedures and mortality rates in the health care sector. In general, high-volume hospitals appear to achieve lower mortality rates, although considerable variation exists. However, most studies focus on US hospitals, which face different incentives than hospitals in a National Health Service (NHS). In order to add to the literature, this study aims to understand what happens in a NHS. Results reveal a statistically significant correlation between volume of procedures and better outcomes for the following medical procedures: cerebral infarction, respiratory infections, circulatory disorders with AMI, bowel procedures, cirrhosis, and hip and femur procedures. The effect is explained with the practice-makes-perfect hypothesis through static effects of scale with little evidence of learning-by-doing. The centralization of those medical procedures is recommended given that this policy would save a considerable number of lives (reduction of 12% in deaths for cerebral infarction).

Public perspective towards social impact of chang e lunar probe program

The present article is based on the MA thesis of Hou Bowen (Ph.D candidate) and on the presentation made at the ISA World Congress of Sociology held in Yokohama (Japan) on July 2014 at the Session on “Assessing Technologies: Global Patterns of Trust and Distrust” of RC23-Sociology of Science and Technology.

Construção de uma responsabilidade europeia além-fronteiras

The suppression of internal border controls has led the European Union to establish a mechanism for determining the Member State responsible for examining each asylum application, with the main intention of deterring asylum seekers from lodging multiple applications and guaranteeing that it will be assessed by one of the States – the Dublin System. Even though it holds on a variety of criteria, the most commonly used is the country of first entrance in the EU. The growing migrating flows coming mainly from Northern Africa have thus resulted in an incommensurable burden over the border countries. Gradually, countries like Greece, Bulgaria and Italy have lost capability of providing adequate relief to all asylum seekers and the records of fundamental rights violations related to the provision of housing and basic needs or inhuman detention conditions started piling up. To prevent asylum seekers who had already displaced themselves to other Member States from being transferred back to countries where their human dignity is questionable, the European Court of Human Rights and the Court of Justice have developed a solid jurisprudence determining that when there is a risk of serious breach of fundamental rights all transfers to that country must halt, especially when it is identified with systemic deficiencies in the asylum system and procedures. This reflexion will go through the jurisprudence that influenced very recent legislative amendments, in order to identify which elements form part of the obligation not to transfer under the Dublin System. At last, we will critically analyze the new rising obligation, that has clearly proven insufficient in light of the international fundamental rights framework that the Member States and the EU are bound to respect, proposing substantial amendments with a view to reach a future marked by high solidarity and global responsibility from the European Union.

Role of Intersectoral Collaboration in Mental Health Policy Formulation And Service Delivery in Saint Lucia

RESUMO: Santa Lúcia pequena ilha de país em desenvolvimento com recursos limitados e é confrontada com uma série de desafios socioeconômicos que exigem soluções criativas e inovadoras. É comprovado que a combinação de recursos entre setores para estabelecer os determinantes social, econômico e ambiental da saúde são uma estratégia útil para melhorar a saúde da população, principalmente a sua saúde mental. Este estudo, o primeiro do seu tipo em Santa Lúcia, procurou examinar até que ponto a disponibilidade de uma política nacional de saúde mental levou a ação intersetorial para o fornecimento de serviços e promoção da saúde mental. Além disso, o estudo examinou o nível de colaboração intersetorial que existe entre as agências que prestam cuidados diretos e serviços de suporte para pessoas com doenças mentais e problemas sérios de saúde mental. O estudo também teve como objetivo identificar os fatores que promovem ou dificultam a colaboração intersectorial e gerar recomendações que possam ser aplicadas para países muito pequenos e com perfis socioeconômicos semelhantes. Os dados gerados a partir de três (3) fontes foram sintetizados para formar uma visão ampla das questões. Uma avaliação da política de saúde mental de 2007, uma avaliação que identifica até que ponto a ação intersetorial atualmente deixa a prestação de serviços de saúde mental e a administração de entrevistas semiestruturadas nas mãos de gestores do programa de diferentes agências em todos os setores. O estudo concluiu que, apesar da disponibilidade de uma política de saúde mental, que articula clara e explicitamente a colaboração intersetorial como área prioritária para ação, quase não existe no sistema de fornecimento atual do serviço. Os provedores de serviços em todos os setores reconhecem que há os benefícios da colaboração intersectorial e com entraves significativos em relação à colaboração intersetorial, que por sua vez, impede uma abordagem nacional para o planejamento e o fornecimento do serviço. A colaboração intersetorial não será possível se os próprios setores dependerem da abordagem direta do setor da saúde ou se a atmosfera geral for ofuscada pela estigmatização das doenças mentais.------------------------------------------------------------------------ABSTRACT: Saint Lucia a small island developing country with limited resources, is faced with a number of socio-economic challenges which require creative and innovative solutions to address. Combining resources across sectors to address the social, economic and environmental determinants of health has proven to be a useful strategy for improving population health in particular mental health. This study, the first of its kind for Saint Lucia sought to examine the extent to which the availability of a national mental health policy led to intersectoral action for mental health promotion and service delivery. In addition the study examined the level of intersectoral collaboration which actually exist between agencies which provide direct care and support services to people with mental illnesses and significant mental health problems. The study also aimed to identify the factors which promote or hinder intersectoral collaboration and generate recommendations which can be applied to extremely small countries with similar socio-economic profiles. Data generated from three (3) sources was synthesized to form a broad picture of the issues. An evaluation of the mental health policy of 2007, an assessment of the extent to which intersectoral action currently exist in mental health service delivery and the administration of semi-structured interviews with program managers from different agencies across sectors to identify implementation issues. The study concluded that despite the availability of a mental health policy which clearly and explicitly articulates intersectoral collaboration as a priority area for action, very little exists in the current service delivery system. Services providers across sectors acknowledge the benefits of intersectoral collaboration and that there are significant barriers to intersectoral collaboration, which in turn hinders a national approach to service planning and delivery. Intersectoral collaboration is not possible if sectors themselves are dependent on a top-down health sector driven and dominated approach, or if the general atmosphere is clouded by stigmatization of mental health illnesses.

Connect to success- consulting program of the U.S. embassy Lisbon creation of a business plan for “Quinta dos I’s”

The purpose of this project is to analyse and evaluate if the rural tourism cottage Quinta dos I’s will be profitable within the first five years of operation. It starts with a brief description of the business, followed by an industry analysis of the rural tourism market in Portugal and an intensive competitor analysis to evaluate Quinta dos I’s’ competitive advantages. The project then defines a marketing plan to generate awareness and establish the cottage in the market. Finally, a financial analysis is performed to examine the outcome of Quinta dos I’s’ recommended strategic activities. The results of this project show that the cottage is profitable after the first year of operation and expects to grow annually.